Handing off dialysis patients from an outpatient to an acute care setting or skilled nursing facility can be a challenge because in many cases the timing of the handoff is often uncertain and abrupt.
LOUISVILLE––The butt fumble was a notable play from a National Football League game played on Nov. 22, 2012, Thanksgiving, between the New York Jets and New England Patriots. In front of a New York home crowd of 79,000 at MetLife Stadium and a primetime television audience of 20 million, Jets quarterback Mark Sanchez collided with the backside of his teammate Brandon Moore and fumbled the ball, which was recovered by the Patriots’ Steve Gregory and returned for a touchdown.
The game and the so-called “butt fumble” in particular are remembered as the low point of the Jets’ 2012 season. The play was ranked as the most embarrassing moment in Jets history by ESPN.
While NFL teams may practice the handoff incessantly to spare themselves of their own “butt fumble,” dialysis staff don’t do as well when it comes to handing off patients from an outpatient to an acute care setting or skilled nursing facility, said Tamara Kear, PhD, RN, CNS, CNN, in her talk, “At the starting gate of patient handoff” during the American Nephrology Nurses Association national Symposium here this past week.
Kear, who has helped to direct review of other important topics, like patient safety, build her study on handoff procedures with research funding from ANNA and the Barbara Prowant Research Fund.
Defining a successful dialysis patient handoff
A patient handoff is the transfer of and acceptance of responsibility for patient care, achieved through effective communication, Kear said. “It is a real-time process of passing relevant patient information from one caregiver to another to ensure continuity and safety of patient care.
“The exchange of information” is key, she said, but relevance is equally important. It doesn’t need to be a “25-year health history” of the patient, she told ANNA attendees, just what is important for continuity of care.
Handoff issues can be a challenge because in many cases the timing of the handoff is often uncertain and abrupt. Citing a March 2016 article in the New York Times with the title, “The most dangerous time at the hospital may be when you leave,” Kear said it is important that the dialysis team work together in an “interprofessional collaboration” to achieve a good handoff.
Kear’s research was based on results from a 50-item questionnaire sent out last November to ANNA’s 9,000 members. Preliminary review of the results showed:
- 827 responses
- 30% came from nurse managers
- majority worked in an in-center hemodialysis unit
- 4% of respondents were in transplant care
The survey showed that 63% of nurses do the handoff using just verbal communication; no special paperwork is filed.
Problem areas for the dialysis patient handoff
Interruptions can wreak havoc in the workplace. “There is no research in nephrology on this, but other specialty studies show interruptions are a problem,” said Kear. And where do most of the problems with hand offs occur? Labs and imaging centers are common, where the exchange of information with physicians often begins.
Kear said there are several implications for nursing practice:
- Dialysis nurses can learn from their emergency room colleagues. “We experience many of the same problems in nephrology nursing. It’s a very fast paced, loud, chaotic environment,” she said.
- Unplanned timing in handoff. It can’t be rushed.Large amounts of information to share in a compressed time
There are many methods of the handoff: face to face, phone calls, medical records (written or EMR), faxes, emails, text message, phone messages. Even notes delivered by the patient.
Important patient factors that can influence a successful handoff include alertness, education, language barrier, knowledge of the illness, environmental factors, a loud and chaotic environment, demands for staff time, distractions, and fatique (particularly among acute dialysis nurses).
Improving the handoff
Kear offered some tips to improve the handoff of patient information.
- Face-to-face or voice to voice is the ideal method of patient handout. “It may not be done more than 50% of time, but we can improve that to 70%,” she said.
- Follow up on missed lab tests, wrong dialysis prescriptions, medication errors, failure to record changes in a patient’s health status.
Kear suggested immediate steps that can be taken to improve the handoff:
- Use standardized tools
- Standardize the handoff process: checklists, education
- Educate staff on proper handoff techniques
- Carve out important time for a handoff
- Avoid interrupting a staff member who is giving a handoff
- Question the handoff data to insure accuracy
- Audit the handoff process and tools; monitor compliance
Could ANNA develop its own toolkit? The survey results showed 73% agreed that a patient handoff tool kit for nephrology would be beneficial.